Avance Home Health, Inc.

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to coordinate care delivery to meet the patient’s needs and involve the patient caregiver to accomplish safe medication administration per physician’s order for two of three sampled patients (Patient 1 and Patient 3) when: 1. Patient 1 did not receive Simvastatin (medication to lower cholesterol [fat-like substance made in the liver, and found in the blood and in all cells of the body]) per physician’s order. 2. Patient 3’ s caregiver did not know the name of medication required refill. These failures had potential for delaying discharge from home health and/or being admitted to emergency room due to incorrect medication administration. 1. During a concurrent observation and interview on 9/10/24 at 3 p.m., in Patient 1’s home, with Home Health Aide (HHA) 1, Patient 1 was observed ambulating with a walker independently. HHA 1 stated Patient 1 lived alone, and he was independent except needing assistance with wound care and showers. After HHA 1’s visit, Patient 1’s medications were reviewed. A pill box was observed on the kitchen counter. Patient 1 demonstrated five medication bottles on the left side of the pill box which was designated as “am (morning) medication” and four medication bottles on the right side of the pill box which was designated as “pm (evening) medication”. Patient 1 stated his son filled his pill box for him. During the review of each medication bottle placed on the kitchen counter, it was observed Simvastatin 10 mg (milligram-unit of measurement) was being grouped in am medications. Patient 1 stated he had been taking Simvastatin in am the way his son filled his pill box. Patient 1 stated he did not know he had been taking Simvastatin at the wrong time. Patient 1 stated the agency knew his son was preparing his medications. During a review of Patient 1’s Medication Profile (list of current medication ordered by physicians) dated 2/24/24 indicated, “…Simvastatin 10 MG Oral Tablet 1 tab QPM (every evening) by mouth (PO)…” During a review of Patient 1’s plan of care (POC-a form contains interventions and goals for the patient as well as medications, prognosis and treatment.) dated 8/22/24 to 10/20/24, the POC indicated the SOC (start of care) was 2/24/24. The POC indicated, “…Patient 1 was 92 years old who was oriented time, place and person but forgetful…Patient lives alone, his son visits twice weekly and assists shopping and ADLs (activities daily living) … Nursing: SN (skilled nursing) to minimize /eliminate risk for hospitalization due to identified problems with medications …” During a phone interview on 9/16/24 at 3:45 p.m. with Registered Nurse (RN) 1, RN 1 stated she knew Patient 1’s son was involved with preparing Patient 1’s medications. RN 1 stated she did not talk with Patient 1’s son to ensure his safe administration of medications. RN 1 stated it was not the agency’s procedure to contact Patient 1’s son who lives out of town. RN 1 stated Patient 1 was independent therefore she did not involve Patient 1’s son in the POC. RN 1 stated she did not know Patient 1 was taking one of his medications at the wrong time. RN 1 stated it was not Skilled Nurses (SN) duty to fill pill box for Patient 1. RN 1 stated she did not have any contact with Patient 1’s son since there was no reason to contact him for significant change of condition. RN 1 stated it was her responsibility to oversee Licensed Vocational Nurses (LVN) to ensure the POC was followed. During an interview on 9/16/24 at 4:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she did not know LVNs were supposed to check whether patients were taking medications correctly on each home visit. The DPCS stated the current practice was to just check any change of medication on each home visit. The DPCS stated since Patient 1 was independent and most likely the nurses had not been checking medications on each visit. During a review of the agency’s policy and procedure (P&P) titled “Coordination of Services with Other Providers” dated 12/2018, the P&P indicated, “…A case Manager will be assigned to be responsible for coordinating services provided to the patient by the organization…the Case Manager will act as liaison with other organizations or individuals also providing care to the patient to assure effective coordination of related services…Ongoing communication regarding issues and concerns with the organization s or individuals providing care will be the responsibility of the [ agency] management team…” During a review of the agency’s P&P titled “Ongoing Assessments” dated 12/2018, the P&P indicate, “…Using the standards of care identified by the organization, the clinician will reassess the patient for…compliance to treatment/or medications…” During a review of the agency’s P&P titled “Medication Monitoring” dated 12/2018, the P&P indicate, “…Ongoing patient medication monitoring will use a collaborative approach between clinicians, physicians, pharmacists, patients, and families/caregivers…” 2. During an observation on 9/12/24 at 12 p.m., in Patient 3’s home, Licensed Vocational Nurse (LVN) 1 provided wound care and asked related questions in Spanish. Patient 3’s caregiver was present who speaks Spanish and English. During the visit, LVN 1 was informed to translate her conversation with Patient 3 and the care giver in English as well. LVN 1 asked Patient 3 if there were any changes in her medications. LVN 1 stated Patient 1 stated “no”. LVN 1 did not have any additional conversation about medications during the visit. During a concurrent observation and interview on 9/12/24 at 12:30 p.m., in the dining room, with Patient 3’s caregiver, Patient 3’s current medications were reviewed. Patient 3’s caregiver brought the medication bottles Patient 3 was currently taking. Patient 3’s caregiver stated, “One of empty bottle needs refill but I don’t know the name of medication…My mother has a tendency to peel label off the medication bottle…I think it’s water pill.” Patient 3’s caregiver stated the agency did not provide a medication profile for Patient 3. Patient 3’s caregiver stated she did not know the purpose of medications or the importance of each medication her mom is taking. Patient 3’s caregiver stated no one from the agency explained the indication or side effects for each medication. During a review of Patient 3’s “Medication Profile” dated 8/2/24, the medication profile indicated, “…Furosemide (a diuretic reduces fluid retention and treats high blood pressure) 20 MG 1 tab BID (twice a day) By mouth (PO)…” During a review of Patient 3’s POC dated 8/2/24 to 9/30/24, the POC indicated, “…The SOC 8/2/24… and principal (primary) diagnosis…cellulitis (a bacterial infection involving the inner layers of the skin) of abdominal wall…skilled nurse developed patient plan of care with patient/caregiver involvement…SN to instruct on medications…” During a phone interview on 9/16/24 at 3:45 p.m., with RN 1, RN 1 stated she reviewed medications thoroughly on the SOC visit to ensure Patient 3 was taking medications as physician ordered. RN 1 stated medications instructions were primarily done by Patient 3’s physician and pharmacist. RN 1 stated the SN would validate safe medication administration as needed such as detected any abnormal vital signs or change of condition. RN 1 stated she did not expect SN to instruct on medications on each visit. During an interview on 9/16/24 at 4:15 p.m., with the DPCS, the DPCS stated she did not know LVNs were supposed to check whether patients were taking medications correctly in each visit. The DPCS stated the current practice was to just check any change of medication on each home visit. During a review of the agency’s P&P titled “Medication Monitoring” dated 12/2018, the P&P indicate, “…Ongoing patient medication monitoring will use a collaborative approach between clinicians, physicians, pharmacists, patients, and families/caregivers…” During a review of the agency’s P&P titled “Care Planning Process” dated 12/2018, the P&P indicate, “…Patient and caregiver education and training that the organization will provide specific to patient’s needs…” During a review of agency’s job description titled “Registered Nurse” dated 12/2018, the job description indicated, “…Initiates appropriate preventative… nursing procedures…Administers medications… as prescribed by the physician. Evaluates patient adherence to the prescribed medication regimen… Performs medication review and reconciles medications as indicated…Counsels the patient and family in meeting nursing and related needs…” During a review of agency’s job description titled “Licensed Practical /Vocational Nurse” dated 12/2018, the job description indicated, “…Evaluates patient adherence to the prescribed medication regimen. Performs medication review and reconciles medications as indicated…””